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■ Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle181(Rev.10/10) Survey Form - Page 1 11 1177502 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection�. Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ��n�� If Referral,choose referral type(Fill one) — <br /> Identifier: S Q F) J O tt to l� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name n Inspected By Inspector <br /> (�)l�` Pr\r12S 1`1'L&�v1r <br /> Physical Address C <br /> Inspection Date <br /> CA b7,0 <br /> Time In Time Out <br /> Business Rep Title l O AM O AM <br /> 3 l ® PM 2l 0 ® PM <br /> PA <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (p &Active 0 Passenger *,Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> A New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 0 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> o U ;�l r�k�u-►5 6-� r I S ow)—cun- <br /> Inspection Form Included: 0 <br /> Comments Included: ® — <br /> S s Sign re Phone Number Inspff <br /> r's Signature one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X7�VE X A E 11213] 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />